Blog
Infertility diagnosis: where does the search for causes begin?
Infertility is not a single disease, but a condition that can have many causes: ovulation disorders, tubal factor, endometriosis, male factor, or a combination of several problems at once. According to the WHO, infertility affects approximately 1 in 6 adults worldwide during their lifetime, so this topic is much more common than is often thought. The WHO also defines infertility as the inability to achieve pregnancy after 12 months of regular unprotected sexual intercourse.
The most important thing in diagnosing infertility is not to try to find one “main cause” at random. The American Society for Reproductive Medicine recommends that the examination be carried out systematically, quickly and with an emphasis on the least invasive methods that help identify the most common causes. This means that good diagnostics are not chaotic set of tests, but a well-thought-out route.
When should you start the examination?
If a woman is under 35 years of age and pregnancy does not occur after 12 months of regular unprotected sex, testing is appropriate. If a woman is 35 years of age or older, evaluation is recommended after 6 months of trying. After 40 years of age, an even faster response is advisable. There is also no need to wait if there are irregular menstruation, amenorrhea, suspected endometriosis, known problems with the uterus or tubes, sexual dysfunction, or suspected male factor.
What is included in the basic diagnosis of infertility?
In the modern approach, the examination usually covers three main areas: whether ovulation is present, whether the fallopian tubes are patent, and whether there is a male factor. The ASRM explicitly states that the evaluation of infertility should include checking the ovulatory status, the structure and patency of the female reproductive tract, and the evaluation of the partner's sperm. In this case, the examination of the man and the woman, whenever possible, should begin in parallel, rather than sequentially.
Table: which examinations are most often included in the diagnosis of infertility
| Direction | What is checked? | What is this for? |
|---|---|---|
| Ovulation | menstrual cycle, hormone tests if necessary | to understand whether the egg is maturing and being released |
| Uterus and ovaries | transvaginal ultrasound | to assess anatomy, fibroids, cysts, endometrial features |
| Pipe throughput | hysterosalpingography or contrast ultrasound | to check if the egg and sperm can meet |
| Male factor | spermogram | to assess sperm count, motility, and other parameters |
| Additional reasons | individual hormones or other tests as indicated | if there is a suspicion of an endocrine or other related problem |
This framework is consistent with ASRM recommendations: transvaginal ultrasound is used to assess the uterus and ovaries, and hysterosalpingography or contrast-enhanced sonographic methods are most commonly used to assess tubal patency. Semen analysis is recommended early in the examination due to the high incidence of male factor.
Is it always necessary to “surrender all hormones”?”
No. This is one of the most common mistakes in diagnosing infertility. If the menstrual cycle is regular — approximately every 21–35 days — additional confirmation of ovulation is not always necessary. The ASRM separately notes that with regular cycles, routine “ovulation” tests are usually not necessary unless there are other suspicious signs. However, prolactin, thyroid hormones, androgens, or 17-hydroxyprogesterone are prescribed only when indicated — for example, with galactorrhea, oligomenorrhea, amenorrhea, or signs of androgen excess.
What is important to know about AMH and ovarian reserve
AMH and other ovarian reserve tests are often thought of as “fertility testing,” but this is oversimplified. The ASRM emphasizes that ovarian reserve tests should complement clinical evaluation, not replace it. They have not been shown to be useful as a screening tool in fertile women and are not a good random “test of future fertility” in the short term.
Why is a spermogram almost always needed?
Infertility diagnosis often mistakenly focuses solely on the woman, but this is an inaccurate approach. The ASRM emphasizes that because of the high incidence of male factor infertility, at least one semen analysis should be performed early in the evaluation. This avoids wasting months testing only one partner when the cause may be partially or completely sperm-related.
When additional research is needed
Not every couple needs complex or invasive tests. The ASRM explicitly states that laparoscopy, advanced sperm function tests, postcoital testing, thrombophilia, immunological studies, karyotyping, endometrial biopsy and prolactin are not included in routine infertility diagnostics without specific indications. This is an important guideline: high-quality diagnostics is not the maximum number of tests, but the correct selection of the necessary ones.
What a well-constructed diagnosis provides
Correct infertility diagnosis is necessary not only to “find the problem”, but also to avoid wasting time on unnecessary steps. It helps to understand whether it is possible to start with ovulation correction, whether the tubal factor needs to be treated, whether the male factor plays a key role, or whether the situation requires assisted reproductive technologies. That is why reproductive medicine values not a separate analysis, but a clear sequence of actions.
Infertility is a topic where time is of the essence, but it is even more important not to waste it on chaotic examinations. The best start is a parallel assessment of both partners, ovulation testing, sperm analysis and tubal patency testing when indicated. This approach provides more clarity and leads to a realistic plan of action much faster.
